Can robotic surgery separate Siamese twins?

How robots are the future of surgery, and how they are already helping prostate operations today
05 August 2022

Interview with 

Mark Slack, CMR Surgical, & Ben Lamb, Addenbrooke's Hospital


the Versius surgical robot


Robots are increasingly making their presence felt in the operating theatre, and this week we heard the heart-warming story of how two Siamese - or conjoined - twins, linked at the head, were successfully separated during a 27 hour long procedure by robotic surgery in Rio De Janeiro. Shortly, we’ll hear from surgeon Ben Lamb about how they are being used to reduce the duration of hospital stays a bit closer to home at Addenbrooke’s Hospital, in Cambridge. But first, on that operation to separate the twins in Brazil, it actually involved 2 teams, one based in the twins’ native Brazil and one at Great Ormond Street in London who worked together using virtual reality projections so they could operate remotely. One of the surgeons, Noor ul Owase, called it ‘space age stuff.’ With us now is Obstetrician and Gynaecology consultant Mark Slack, who’s also the founder of CMR Surgical, whose technology can do similar sorts of things...

Mark - Well, there was one done the day before 9/11, between Strasbourg and New York, but the company doing it laid a cable. So it was a bit of a publicity stunt. Of course, we've got the speed of light and what you get is a lag. So if a surgeon is operating in London on a patient in Sydney, when they move their hand there is a bit of a delay until you see the instrument move on the screen. But with 5g technology I'm sure we'll get there. But at the moment, what we've got is remote mentoring and remote looking after. So with my robot called 'Versius,' when we did our first chest operation because of the pandemic, our proctors and mentors couldn't travel. So the first chest case done in Germany was supervised by a surgeon in Middlesborough, in England.

Mark - And over the course of the pandemic, we did many, many more cases. And in the past, when you're learning a new procedure you either had to get a surgeon to come to your hospital, or you had to travel to visit them. And that's enormously difficult, especially when they are so busy. And now an enormous amount of Versius' introduction to new hospitals is supervised and mentored by a surgeon in another city or in another country. And we in fact have actually partnered with a British company. We've actually now created the infrastructure, so when you buy our robot, you get all this remote mentoring stuff as well.

Chris - So the point being that you are teaching people without actually having to be there, you don't have to fly people all the way around the world to sit in teaching sessions. You can teach them where you can see in virtual reality, what they're seeing, and you can have a shared learning experience.

Mark - Absolutely. So at the moment, we don't have that in virtual reality, we just have it on a screen. Virtual reality is in development but it's also worth mentioning when we train people, we train a very significant partner on virtual reality. So in the old days, if you wanted to learn a new robot, you'd have to go to the hospital and sit on one and practice. You can now sit in your lounge at home with a VR headset and play at the hand controls and practice all you want.

Chris - Nevertheless, though, if you are conducting an operation in a remote part of the world, you can have mentoring for that surgery, presumably by a surgeon who is in London, watching what's going on in Brazil. And they can see and almost experience what is happening to that patient. And they can therefore give insight. They can give hints and tips.

Mark - Absolutely and we are developing ways of communication for them so they use the same terms and so on. But a significant number of our new surgeons using the Versius robot for the first time are supervised by people in other countries and other cities.

Chris - And you said that the other people who did this laid a cable in order to make sure there were no delays or jitter or anything. Do you think it is beyond the realms of possibility that we will be entering a realm where you do get surgery conducted by people who are not in the same room as the patient they're operating on?

Mark - I think Chris, I think we will. The first step will be that the patient being operated on will have a competent surgeon in the theater, but they may not have done the complexity, like the incredible case you just described at the beginning of the piece. And the other surgeon at the moment will just say 'you shouldn't cut there' or 'you should cut there'. I think sooner than you'll imagine we'll have a situation where the surgeon will say 'can I just take control for a few minutes' and do the intricate bit, and then hand it back to the surgeon on the ground.

Chris - A bit like we do with airplanes.

Mark - Correct.

Chris - I mean, there are ways of flying aircraft remotely, and it's probably not dissimilar then.

Mark - It is, and the headsets are the one thing that's really made me see it potentially come true because then the two surgeons will be seeing exactly the same view.

Chris - Yeah. It's not like looking over someone's shoulder and getting a slightly different view. You are seeing what they are seeing.

Mark - Exactly. And so at the moment we are pretty close to that already, but the next stage will be saying 'oh, can I just take control for a second and just give you a pointer'. And then it just improves the quality of surgery and quality of training.

Chris - And just briefly, is there an additional point here? Because if you take, say, cars as an example. Cars can learn from how their driver responds to different road conditions and they share that learning with the whole fleet of cars electronically. So the cars are better at doing their own collision avoidance and so on in the future. Can your robot look at what a surgeon does, look at what it thinks it should do and then think 'well he or she did it differently. Why did they do it differently? There's a learning point there', and then share that knowledge?

Mark - You're reading my mind. The next big thing in surgery is standardization and every movement our robot does is measured and sent up to a cloud. And we actually tested it recently. We taught it to distinguish between a novice and an expert. And it identified seven out of eight of both groups, and then we looked at the videos and the one novice was pretty amazing. And the one expert wasn't so good.

Chris - And it wasn't Mark himself. You'll be relieved to hear. That was Mark Slack, he's the founder of CMR Surgical.

Julia - As we mentioned just now, robots are also helping us cut down the times patients spend in hospital. Consultant urologist Ben Lamb has had some very encouraging results with this. So Ben, what have you been using robots to do?

Ben - So we've been using robots for a number of years now to treatment with prostate cancer and it's an operation where we removed the entire prostate with cancer contained in the hope of curing them of the disease.

Julia - What is the scale of this difference then? So when you're using the robot versus before?

Ben - So traditionally doing an open operation, so a big cut down the tummy for men with prostate cancer, patients could expect to be in hospital anywhere from five to seven days with a significant amount of blood loss and a pretty slow recovery with risk of complications. The use of robotics, which allows us to get right deep down inside the patient's pelvis to the prostate, very carefully dissecting the prostate out and preserving the other good organs that you still need afterwards. It means that we, consistently and reliably at Addenbrooke's now, send patients home usually within 24 hours of their surgery. They're up the same day as their operation. They're going home the following morning. The complication rates are much lower. The recovery's faster, back to family quicker, back to work quicker, and getting back to normal life quicker.

Julia - And at the minute, is this procedure done for every patient who needs the operation or is it sort of a case by case basis?

Ben - I mean the UK's lucky actually. I think we have some of the highest rates in the world of robotic surgery for men with prostate cancer. And I think that's thanks to the organization of cancer care in the NHS. So men in the UK can expect to have this technology in their treatment for prostate cancer. I think what we've done at Addenbrooke's is to push this one step forward, use an enhanced recovery program, training nurses using the day case unit to make sure that we can do this for a hundred percent of patients getting them all home the first day after surgery.


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